Soft tissue injuries may be the result of a wide range of activities and successful recovery requires rehabilitation. Throughout this disclosure, various discussions of soft tissue injuries and rehabilitation are addressed as they are related to sports such as golf. Those skilled in the art will appreciate that this discussion is to assist in understanding features and techniques, but embodiments disclosed herein may be used to treat soft tissue injuries from other sports, work, or leisure activities.
As of 2004 there were more than 27.8 million golfers in the United States, including about 6 million avid golfers who play 25 rounds or more of golf per year. The average golfer typically plays 3-7 rounds of golf per year, and much more time is often spent on the practice range.
According to statistics from 1996, more than 36,400 people presented to the emergency room as a result of golf-related injuries, including injuries related to the swing itself.
A proper golf swing subjects a golfer to a large amount of torque, rotation, side bending and flexion. Due to compound movements involved in the golf swing, many injuries can occur to various body parts. Statistics from the Titleist Performance Institute identify the most common types of injuries among amateur golfers as sprain/strain; tendonitis; arthritis; disc injuries; and tears or fractures.
A study of golf-related injuries in the amateur population indicated the most common injuries were to the following regions and areas (in descending frequency): lower back, left elbow, left shoulder and left wrist. The most common cause of injuries among amateurs is a result of poor or aberrant mechanics. The most common cause of injuries to professional golfers is overuse. It is likely that 50% of touring professionals will sustain an injury that will prevent participation for 3 to 6 weeks. Additionally, about 50% of golfers (amateur or pro) will develop chronic problems particularly if they continue to reproduce aberrant biomechanics without addressing the musculoskeletal etiology.
Regardless of whether an injury was related to playing golf or some other mode, an injury to soft tissue affects the entire body. The spine is one part of the body which is susceptible to injuries. For example, the cervical spine is composed of 7 articulating vertebra that allow for 6 ranges of motion: extension, flexion, right and left rotation and right and left side bending. The cervical spine is also supported by a complex series of muscles and ligaments that help to support and stabilize the head neck. The cervical spine is a very mobile part of the spine, but unfortunately, with mobility often comes instability. The series of muscles that support the cervical spine are an integral part to providing stability. The cervical spine muscles in conjunction with the thoracic spine muscles provide postural integrity and support. Many times forward head posture leads to mechanical instability as the weight of the head causes loss of cervical spine lordosis. When the head is placed in a protracted position in which the ears are not in line with the shoulders and the chin juts forwardly, the weight of the head is placed in a biomechanical disadvantage: the anterior and posterior muscles of the cervical spine now require far greater amounts of stability which often cause them to guard against spasm. This in turn also adds strain and stress on the trapezius and levator scapula muscle groups, and subsequently into the shoulder rotators.
Inferior to the cervical portion of the spine, the thoracic portion is composed of 12 articulating vertebrae that are supported by the rib cage. The amount of torsion and rotation generated in the golf swing can be limited by the amount of thoracic range of motion. Many postural abnormalities such as hyper-kyphosis (i.e., an increase in the amount of curve in the mid back) will cause many golfers to set up their golf swing with what is commonly referred to as a C-posture. The C-posture is described as an excessive roundness in the upper back and can be caused by one or more of the following:    1) Limited thoracic spine extension;    2) Upper Crossed Syndrome—muscle imbalances including tight pecs, lats, upper traps, and levator scap and weakness in the mid-scapular muscles, serratus anterior, lower traps, and deep neck flexors;    3) Scapular instability; and    4) Instability in the core muscles causing poor posture and the slouched forward position at address.
Low back pain is the most common injury that affects the amateur and professional golfer. Some of the more common back injuries among golfers include sprain strain of muscles, SI joint and other soft tissues; facet syndrome; disc pathology; spinal stenosis; and degenerative joint/disc disease.
A recently published study in The Journal of Physical Therapy in 2005 found that there were several factors that were high predictors of lower back pain in golfers. They are as follows:                1) Body Mass Index—(BMI)—this is considered the strongest protector for low back pain in golfers. Golfers with a below average BMI (e.g., less than 25.7 kg/m2, which is typical in relatively tall, slender golfers) were more likely to experience low back pain that short heavy golfers;        2) Side Bridge Endurance Test—subjects in which left side bridge endurance time was greater than right side bridge endurance time by greater than 12.5 seconds reported more episodes of low back pain; and        3) Lead Hip Internal Rotation—professional golfers who experience low back pain in the previous 12 months also generally had reduced range of internal rotation of their lead hip.        
Another area of the body that is susceptible to injuries, especially golf-related injuries, is the shoulder. The shoulder includes the rotator cuff, which is comprised of four muscles: supraspinatus, infraspinatus, subscapularis and teres minor. The shoulder joint is composed of three joints: the glenohumeral joint; the acromioclavicular joint; and the scapular thoracic region.
The majority of the population (golfers and non-golfers alike) present with shoulder external rotators that are significantly weaker than the internal rotators. This is a common trait of the slouched posture. The most common shoulder injuries related to golf include rotator cuff tendonitis, biceps tendinitis, impingement and labral tears.
Golfers that lack thoracic range of motion with extension and rotation are more prone to shoulder injuries bilaterally. As a result, the risk of a shoulder injury is more prominent in one shoulder than the other (e.g., the risk of injury to the left shoulder is higher than the risk of a shoulder injury to the right shoulder in a right-handed golfer).
The left shoulder is the lead shoulder in a right-handed golfer. The backswing requires the left shoulder to maneuver into horizontal adduction, pronation, and flexion during the “take away” phase of the golf swing. This position of the shoulder commonly causes impingement of certain rotator cuff muscles, which typically occurs when the glenohumeral head compresses the supraspinatus tendon in the subacromial space.
Another area of the body that is at risk for injury, particularly in golfers, is the hip. The hip muscles are commonly divided into four groups: the gluteal group (including gluteus maximus, gluteus medius, gluteus minimus and tensor fasciae latae); the lateral rotator group; the adductor group; and the iliopsoas group. In a right-handed golfer the left hip is considered the “lead” hip. The right hip is the trail hip and requires a full amount of internal rotation during the backswing.
Ranges of motion of the hip that are integral to the golfer allowing him or her to efficiently rotate the torso independently of the upper body primarily involve the hip internal and external rotators. The hip should have the ability to rotate 30 degrees internally and 40 degrees externally. When the golfer stands over the ball the hip is now “loaded”—this now requires full hip range of motion independent of trunk or torso range of motion. Many golfers demonstrate ranges of motion that are greater when tested in a seated or prone/supine position because many times the range of motion of the hip is recruited by using the spine or pelvis. When the hip is “loaded” it is now much more important for the range of motion of the hip to occur in the hip joint proper. When a golfer is unable to adequately rotate the right hip during the golf swing they often will “sway” on the backswing and likely “slide” on the downswing. The stability and flexibility of the gluteus medius muscle is paramount throughout the golf swing.
Another area of the body susceptible to injuries is the foot/ankle. Golf is played from the ground up, the only contact that a golfer has with the ground is the feet. The foot/ankle complex mobility is paramount to an effective and efficient golf swing. Foot and ankle mobility are determined by flexibility of the calf and anterior shin muscles (i.e., soleus, gastrocnemius and tibialis anterior). The tibialis anterior is located in the front of the lower leg, and tightness of this muscle will limit the ability to point the toes downward (or “plantarflex” the foot).
Treatment for injuries to any of the above mentioned areas, as well as other muscles or soft tissues, are generally include some form of ischemic pressure, movement-based muscle treatment, kneading, stretching (including static and active), and/or massage.
A common treatment for patients with strains and other injuries is to place two tennis balls in a sock and to tie each end of the sock keeping both balls in close proximity. In the case of soft tissue injuries near the spine, this practice includes positioning the balls along the spine (i.e., one ball on each side of the spinous process) and then applying pressure by lying on the balls (or pressing against the balls from a seated position as dictated by the patient's ability) to apply the appropriate amount of pressure. Variations generally include a golf ball, a lacrosse ball, a softball, etc., which are determined by the body region and amount of pressure generated to allow for therapeutic benefit.
Another common treatment is the use of foam rollers. Traditional foam rollers are formed with a solid surface which does not allow for the many contoured surfaces in the body. As such, in an attempt to contact a desired tissue, positioning a traditional foam roller might apply pressure to bony tissue.
Prior art approaches to enabling self-massage and self-manipulation rely on the ability of the patient to manipulate a generic smooth surface into contact with the desired tissue, the ability of the patient to select two balls having equal properties and position them into the proper configuration, and other variables. The varying resources, skill, and even range of motion of the patient could affect the amount of effort necessary to position a device on the desired tissue, resulting in a wide variance in the effectiveness of any device or prescribed therapy protocol.